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Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials
Open accessAbstract
Background There is substantial interest in chocolate and flavan-3-ols for the prevention of cardiovascular disease (CVD).Objective The objective was to systematically review the effects of chocolate, cocoa, and flavan-3-ols on major CVD risk factors.Design We searched Medline, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) of chocolate, cocoa, or flavan-3-ols. We contacted authors for additional data and conducted duplicate assessment of study inclusion, data extraction, validity, and random-effects meta-analyses.Results We included 42 acute or short-term chronic (≤18 wk) RCTs that comprised 1297 participants. Insulin resistance (HOMA-IR: -0.67; 95% CI: -0.98, -0.36) was improved by chocolate or cocoa due to significant reductions in serum insulin. Flow-mediated dilatation (FMD) improved after chronic (1.34%; 95% CI: 1.00%, 1.68%) and acute (3.19%; 95% CI: 2.04%, 4.33%) intakes. Effects on HOMA-IR and FMD remained stable to sensitivity analyses. We observed reductions in diastolic blood pressure (BP; -1.60 mm Hg; 95% CI: -2.77, -0.43 mm Hg) and mean arterial pressure (-1.64 mm Hg; 95% CI: -3.27, -0.01 mm Hg) and marginally significant effects on LDL (-0.07 mmol/L; 95% CI: -0.13, 0.00 mmol/L) and HDL (0.03 mmol/L; 95% CI: 0.00, 0.06 mmol/L) cholesterol. Chocolate or cocoa improved FMD regardless of the dose consumed, whereas doses >50 mg epicatechin/d resulted in greater effects on systolic and diastolic BP. GRADE (Grading of Recommendations, Assessment, Development and Evaluation, a tool to assess quality of evidence and strength of recommendations) suggested low- to moderate-quality evidence of beneficial effects, with no suggestion of negative effects. The strength of evidence was lowered due to unclear reporting for allocation concealment, dropouts, missing data on outcomes, and heterogeneity in biomarker results in some studies.Conclusions We found consistent acute and chronic benefits of chocolate or cocoa on FMD and previously unreported promising effects on insulin and HOMA-IR. Larger, longer-duration, and independently funded trials are required to confirm the potential cardiovascular benefits of cocoa flavan-3-ols.
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“In this regard, the level of flavanols used in this current study is comparable to the level of cocoa flavanols fed in previous studies where improvements in brain blood flow, 19 vascular function, and blood pressure were observed.25”
From Benefits in Cognitive Function, Blood Pressure, and Insulin Resistance Through Cocoa Flavanol Consumption in Elderly Subjects With Mild Cognitive Impairment: The Cocoa, Cognition, and Aging (CoCoA) Study (2012) · cites this paper as [25]
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“In this regard, although we did not specifically evaluate the effect of cocoa flavanols on endothelial function, a number of studies, some also from our group, clearly demonstrated the ability of flavonoids to improve NO bioavailability in vasculature, 17,18,25 which, in turn, plays a pivotal role in modulating cerebrovascular tone.28”
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“Regarding flavonoids, Desideri and colleagues administered 990 or 520 mg of n-3 FLAV, with a Cohen’s d of 1.64 reported for the lower dose, which closely corresponds to that in our trial [22].”
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(−)-Epicatechin Attenuates Degradation of Mouse Oxidative Muscle Following Hindlimb Suspension
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“Moreover, the results of 2 meta-analyses indicate that moderate consumption of cocoa, by human participants, is effective in preventing cardiovascular disease (47) because it improves flow-mediated dilatation and insulin resistance (12).”
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Cardioprotective Mechanisms of Cocoa
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“However, it did not confirm the effect of cocoa and chocolate on glycated hemoglobin (HbA1c) (44).”
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“This may be explained by a reduction in blood pressure [2–6] and serum lipids [2,7,8] and by an increase in insulin sensitivity [2,7], which could be observed in several meta-analyses of randomized controlled trials (RCTs).”
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“In contrast to adverse effects on health associated with increased intakes of added sugars and saturated fat, evidence suggests that consumption of cocoa, a component of chocolate candy, may be associated with beneficial effects on cardiovascular risk factors [12-15].”
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“Consequently, the effect of reducing blood pressure or blood lipids may be more pronounced on the CVD type with which the risk factor is more strongly associated [32].”
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Diabetes and Chocolate: Friend or Foe?
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Flavonoids Seen through the Energy Perspective
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“The bulk of the existing literature supports the blood pressure-lowering effects of high-flavanoid cocoa consumption (18, 19, 24, 25, 28).”
BackgroundDietary supplements: clinical cholesterol-lowering efficacy and potential mechanisms of action
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“Consumption of cocoa extracts, mainly flavan-3-ols, was also found to lower plasma LDL cholesterol levels by 0.07–0.08 mmol/L and increase HDL cholesterol levels by 0.03–0.05 mmol/L (Shrime et al. 2011; Hooper et al. 2012).”
BackgroundInfluential
Metadata
- Authors
- Hooper, L., Kay, C., Abdelhamid, A., Kroon, P. A., Cohn, J. S., Rimm, E. B., & Cassidy, A.
- Affiliations
- University of East Anglia (GB)
- Corresponding author
- Hooper, Lee
- Venue
- The American Journal of Clinical Nutrition
- Publisher
- Elsevier BV
- Published
- 2012-03
- Volume
- 95
- Issue
- 3
- Pages
- 740-751
- ISSN
- 0002-9165 (ISSN-L)
- OpenAlex
- W2129761592
- Cited by
- 610
- References
- 90
- Citations by year
- 2026: 15 · 2025: 19 · 2024: 32 · 2023: 24 · 2022: 29 · 2021: 35 · 2020: 37 · 2019: 43 · 2018: 63 · 2017: 56 · 2016: 64 · 2015: 54 · 2014: 50 · 2013: 66 · 2012: 22
- FWCI
- 6.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- American Journal of Clinical Nutrition (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Research Portal (Queen's University Belfast) (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Funders
- GlaxoSmithKline
- Directorate for Biological Sciences
- Biotechnology and Biological Sciences Research Council (BBS/E/F/00044434)
- Topics
- Health Sciences › Medicine › Biochemistry (medical) › Phytochemicals and Antioxidant Activities
- Life Sciences › Agricultural and Biological Sciences › Food Science › Food Chemistry and Fat Analysis
- Health Sciences › Medicine › Pharmacology (medical) › Coffee research and impacts
- Keywords
- chocolate, Theobroma cacao, flavan-3-ols, epicatechin, cardiovascular disease prevention, insulin resistance, flow-mediated dilation, endothelial function, blood pressure, LDL cholesterol, HDL cholesterol, cardiovascular risk factors, dose-response relationship, quality of evidence, GRADE, adverse effects
- MeSH terms
- Blood Glucose, Blood Pressure, Cacao, Candy, Cardiovascular Diseases, Cardiovascular System, Flavonoids, Humans, Insulin, Risk Factors, Reproducibility of Results, Biomarkers, Randomized Controlled Trials as Topic
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